Auxiliary surgical field visualization system

ABSTRACT

An auxiliary surgical field visualization system is described, which includes an auxiliary surgical field camera, configured for acquiring an image of a field of view of a secondary surgical field, wherein the secondary surgical field includes the exterior of a patient&#39;s eye undergoing vitreoretinal surgery. The auxiliary surgical field visualization system also includes a display in electronic communication with the auxiliary surgical field camera, wherein the display is configured for receiving, from the auxiliary surgical field camera, a signal that includes the image of the field of view of the secondary surgical field, and upon receiving the signal, displaying the image of the field of view of the secondary surgical field.

BACKGROUND

The present disclosure relates to ophthalmic surgery, and morespecifically, to an auxiliary surgical field visualization systemconfigured to provide a view of a secondary surgical field thatencompasses an area including the exterior of an eye and the surroundingarea, during vitreoretinal surgery on the eye.

In ophthalmology, eye surgery, or ophthalmic surgery, saves and improvesthe vision of tens of thousands of patients every year. However, giventhe sensitivity of vision to even small changes in the eye and theminute and delicate nature of many eye structures, ophthalmic surgery isdifficult to perform and the reduction of even minor or uncommonsurgical errors or modest improvements in accuracy of surgicaltechniques can make an enormous difference in the patient's vision afterthe surgery.

Ophthalmic surgery is performed on the eye and accessory visualstructures. More specifically, vitreoretinal surgery encompasses variousdelicate procedures involving internal portions of the eye, such as thevitreous humor and the retina. Different vitreoretinal surgicalprocedures are used, sometimes with lasers, to improve visual sensoryperformance in the treatment of many eye diseases, including epimacularmembranes, diabetic retinopathy, vitreous hemorrhage, macular hole,detached retina, and complications of cataract surgery, among others.During vitreoretinal surgery, for example, an ophthalmologist typicallyuses a surgical microscope to view the fundus through the cornea, whilesurgical instruments that penetrate the sclera may be introduced toperform any of a variety of different procedures. Typically, duringvitreoretinal surgery, the fundus is illuminated using endoillumination,wherein a light source, such as a fiber optic light, is introduced intothe internal portion of the eye through the sclera and the surgicalmicroscope provides high magnification imaging of the fundus and otherinternal structures of the eye during vitreoretinal surgery viewablethrough the pupil of the eye.

During vitreoretinal surgery, the internal portion of the eye may beconsidered the primary surgical field. Accordingly, the field of view ofthe surgical microscope directed toward the endoilluminated internalportion of the eye may be considered the primary surgical field of view.During vitreoretinal surgery, various procedures may take place outsideof the primary surgical field of view, such as procedures that takeplace on or adjacent to the exterior surface of the eye, includingmanipulation of various instruments, suturing, and so on. Additionally,during vitreoretinal surgery, various surgical components outside of theprimary surgical field, such as infusion lines and so on, sometimesrequire visual inspection, so that it can be verified that the surgicalcomponents are performing as required. Existing vitreoretinal surgerysystems do not allow the ophthalmic surgeon and others in the operatingroom to conveniently and quickly view procedures and components outsideof the primary surgical field of view. However, development ofophthalmic surgery systems to allow the ophthalmic surgeon and others inthe operating room to conveniently and quickly view procedures andcomponents outside of the primary surgical field of view remainschallenging.

SUMMARY

The present disclosure relates to an auxiliary surgical fieldvisualization system that includes an auxiliary surgical field camera.The auxiliary surgical field camera is configured for acquiring an imageof a field of view of a secondary surgical field, wherein the secondarysurgical field includes the exterior of a patient's eye undergoingvitreoretinal surgery. The auxiliary surgical field visualization systemalso includes a display in electronic communication with the auxiliarysurgical field camera, wherein the display is configured for receiving,from the auxiliary surgical field camera, a signal that includes theimage of the field of view of the secondary surgical field, and uponreceiving the signal, displaying the image of the field of view of thesecondary surgical field.

In any of the disclosed implementations, the auxiliary surgical fieldvisualization system may further include the following details, whichmay be combined with the above system and with one another in anycombinations unless clearly mutually exclusive:

(i) the eye may be illuminated using endoillumination;

(ii) the secondary surgical field may have a light intensity of lessthan 2000 lux;

(iii) the auxiliary surgical field camera may be an infra-red camera, alow-light camera, or a night vision camera;

(iv) the area of the field of view of the secondary surgical field maybe between about 3 cm² and 36 cm²;

(v) the image may be a real-time image;

(vi) the display may be further configured to receive, from a primarysurgical field camera configured for acquiring an image of a field ofview of a primary surgical field including an internal view of apatient's eye undergoing vitreoretinal surgery, a signal that includesthe image of the field of view of the primary surgical field, anddisplaying the image of the field of view of the primary surgical field;

(vii) the display may be configured for simultaneously displaying theimage of the field of view of the secondary surgical field and the fieldof view of the primary surgical field;

(viii) the display may be a standard definition (SD) display, a highdefinition (HD) display, a cathode ray tube (CRT) display, a projectionscreen display, a liquid crystal display (LCD), an organic lightemitting diode (OLED) display, a plasma display, a light emitting diodes(LED) display, or a 3-dimensional (3D) display;

(ix) the auxiliary surgical field visualization system may include anNGENUITY® 3D Visualization System;

(x) the auxiliary surgical field visualization system may include aprocessor and a non-transitory computer-readable medium accessible bythe processor, wherein the non-transitory computer readable mediumcontains instructions executable by the processor for receiving, fromthe auxiliary surgical field camera, a signal that includes the image ofthe field of view of the secondary surgical field, and upon receivingthe signal, sending the signal to the display;

(xi) the non-transitory computer-readable medium may includeinstructions executable by the processor for receiving, from a primarysurgical field camera configured for acquiring an image of a field ofview of a primary surgical field comprising an internal view of apatient's eye undergoing vitreoretinal surgery, a signal that includesthe image of the field of view of the primary surgical field, and uponreceiving the signal, sending the signal to the display;

(xii) the auxiliary surgical field visualization system may allowvisualization on a display of one or more secondary surgicalmanipulations, wherein the secondary surgical manipulations are directedto a site on or adjacent to the exterior surface of the eye;

(xiii) the secondary surgical manipulations may include one or moremanipulations selected from inserting an instrument into the eye througha trocar cannula, suturing an exterior surface of the eye, placing atrocar cannula, removing a trocar cannula, inspecting a function of asurgical component, retrieving a foreign body, placing indentors ormuscle hooks, using cryo-probes, placing scleral buckles and encirclingbands, and placing a direct or an indirect contact lens;

(xiv) the auxiliary vitreoretinal surgery visualization system may allowvisualization on a display of one or more surgical components in thesecondary surgical field;

(xv) the surgical components in the secondary surgical field may beselected from a trocar cannula, an infusion line, a needle holder, anindentor, a muscle hook, an instrument tip prior to insertion trough atrocar cannula, a flexible iris retractor, a direct or indirect contactlens, and a needle and suture; and

(xvi) the display may be viewable by a plurality of individuals.

BRIEF DESCRIPTION OF THE DRAWINGS

For a more complete understanding of the present invention and itsfeatures and advantages, reference is now made to the followingdescription, taken in conjunction with the accompanying drawings, whichare not to scale, and in which:

FIG. 1 is an exemplary schematic showing a side view of an eyeundergoing a vitreoretinal surgical procedure;

FIG. 2 is an exemplary schematic showing a top-down view of an eyeundergoing a vitreoretinal surgical procedure;

FIG. 3A is a schematic showing an exemplary auxiliary surgical fieldvisualization system;

FIG. 3B is another schematic showing an exemplary auxiliary surgicalfield visualization system;

FIG. 3C is yet another schematic showing an exemplary exemplaryauxiliary surgical field visualization system;

FIG. 3D is yet another schematic showing an exemplary exemplaryauxiliary surgical field visualization system;

FIG. 4 is a schematic showing an example of a picture-in-picture view ofan image captured by an auxiliary surgical field camera displayedtogether with an image of a view of an endoilluminated interior portionof an eye undergoing vitreoretinal surgery, as displayed on a displayused as part of an NGENUITY® 3D Visualization System.

FIG. 5A is a schematic showing an exemplary attachment position of anauxiliary surgical field camera on the housing of a surgical microscope.

FIG. 5B is a schematic showing an exemplary attachment position of anauxiliary surgical field camera on the housing of a surgical microscope.

DETAILED DESCRIPTION

In the following description, details are set forth by way of example tofacilitate discussion of the disclosed subject matter. It should beapparent to a person of ordinary skill in the art, however, that thedisclosed embodiments are exemplary and not exhaustive of all possibleembodiments.

The present disclosure relates to ophthalmic surgery, and morespecifically, to an auxiliary surgical field visualization systemconfigured to provide a view of a secondary surgical field thatencompasses an area including the exterior of the eye and thesurrounding area, during vitreoretinal surgery.

For example, FIG. 1 is an exemplary schematic showing a side view of aneye undergoing a vitreoretinal surgical procedure. Indicated in theschematic diagram are various tools inserted into the eye, including avitrector cutting device 101 that removes the eye's vitreous gel in aslow, controlled fashion. Also shown is a light pipe 102, which providesillumination inside the eye, referred to as endoillumination. Also shownis an infusion cannula 103, used to replace fluid in the eye with asaline solution and to maintain proper eye pressure. The vitrectorcutting device 101, the infusion cannula 102, and the light pipe 103 aretypically inserted into the eye through respective trocar cannulas 104,105 and 106 that are inserted into incisions in the sclera following aprocedure using a trocar cannula system, as would be understood byskilled persons. During a vitreoretinal surgery, such as shown in theexemplary schematic diagram in FIG. 1, the ophthalmic surgeon visualizesthe illuminated portion of the fundus 107 using a microscope directed toview the internal part of the eye through the pupil 108.

FIG. 2 is a schematic showing an exemplary top-down view, correspondingto an en face view of an eye undergoing an exemplary vitreoretinalsurgical procedure, similar to the exemplary procedure shown inside-view in FIG. 1. Indicated in the schematic diagram are varioustools inserted into the eye through trocar cannulas 208, including avitrector cutting device 201, an infusion cannula 202, and a light pipe203. During a vitreoretinal surgery, such as shown in the exemplaryschematic diagram in FIG. 2, the ophthalmic surgeon visualizes theendoilluminated portion of the fundus 204 using a microscope directed toview the internal part of the eye through the pupil 205.

Typically, during vitreoretinal surgery, the ophthalmic surgeon viewsthe endoilluminated portion of the eye at high magnification.Accordingly, at high magnification, the region of the eye viewableduring surgical manipulations involving the endoilluminated internalportion of the eye encompasses a relatively small area of the en faceview of the eye, for example as shown by a dashed line box indicating aview of the primary surgical field 206 in FIG. 2.

Also shown in FIG. 2 is a dashed line box indicating a secondarysurgical field 207. The term “secondary surgical field” as used hereinrefers to a region that generally encompasses an area including theexterior surface of the eye and the surrounding area, duringvitreoretinal surgery. Accordingly, the secondary surgical fieldencompasses a region including an exterior portion of the eye and thesurrounding area, in which various surgical manipulations may take placeduring vitreoretinal surgery, and may include, but are not limited to,the externally viewable features of the eye, for example includingexternally viewable portions of the pupil, iris, cornea, sclera,vessels, and incision sites, e.g., within the sclera, and also mayinclude facial structures surrounding the eye that may be viewableduring ophthalmic surgery such as eyelids, eyelashes, eyebrow, nose,cheeks, and so on. The secondary surgical field may also include variousexternally viewable surgical components such as surgical tools,instruments, tubing, clamps, infusion cannulas, light pipes, vitrectorcutting devices, trocar cannulas, cue-tips, drapes, speculum,visualization apparatus e.g. BIOM® (Oculus Optikgeräte GmbH,Wetzlar-Dutenhof, Germany), direct or indirect contact lenses, IOL,injectors, cutting devices, needle holders, indentors, muscle hooks,instrument tips prior to insertion trough a trocar cannula, flexibleiris retractors, needles and sutures and other objects identifiable byskilled persons, that may be used during ophthalmic surgery, that may beintroduced into the general external area of the eye undergoing surgery.The term “externally viewable” in general indicates something that isviewable within the secondary surgical field, such as something that isexterior to the eye, or on or near the exterior surface of the eye. Inparticular, the term externally viewable refers to something that maynot be viewable within the primary surgical field, such as the variousfeatures of the eye and surrounding facial features and surgicalinstruments described herein. The term secondary surgical field includesthe exterior portion of the eye that is not typically viewable usingendoillumination. Accordingly, the term secondary surgical field as usedherein generally refers to a surgical field that is supplementary,auxiliary, or additional to the primary surgical field, generallyincluding a spatial region that includes the external portion of the eyeand the area surrounding the eye, or adjacent to the eye, duringvitreoretinal surgery.

It will be apparent to skilled persons that the secondary surgical fieldis generally larger than the primary surgical field, and may encompassan approximately en face area when viewed top-down, for example as shownin FIG. 2, between, or between about, 1 cm² and 36 cm², for example anarea encompassing approximately a square area of between, or aboutbetween, e.g., 1 cm×1 cm, and e.g. 6 cm²×6 cm², although other shapesare possible, such as rectangular areas. The angle of the 2-dimensionalplane of the en face area of the external surgical field may be thesame, or may be different, to the angle of the 2-dimensional plane ofthe en face area of the primary surgical field.

In general, surgical procedures described herein include primarysurgical manipulations and secondary surgical manipulations. The term“primary surgical manipulations” refers to surgical manipulations thatare viewable at high magnification in the primary surgical field, suchas manipulations that target the interior of the endoilluminated eye. Incontrast, the term “secondary surgical manipulations” refers to surgicalmanipulations that may be viewable at lower magnification and may beperformed in the secondary surgical field, such as manipulations thatgenerally target the exterior portion of the eye or are viewable takingplace on or adjacent to, or in close proximity to (e.g., within about 5cm) of an exterior surface of the eye.

For example, secondary surgical manipulations include procedures such asmanipulation of various instruments, suturing, and so on, that takeplace on or near the exterior portion of the eye. In particular, forexample, during vitreoretinal surgery, insertion of instruments throughtrocar cannulas requires visualization of the insertion location on theoutside of the eye, such that the cannula hub and the instrument tipneeds to be visualized for successful introduction. This requiresvisualization at lower magnification, or of a larger field of view,and/or on a different focal plane, than is used for viewing primarysurgical manipulations that target structures inside the eye.

Additionally, during vitreoretinal surgery, visual inspection ofportions of various surgical components in the secondary surgical field,such as infusion lines and so on, may be required from time to time, sothat it can be verified that the surgical components are performing asrequired. Visual inspection of the components may also require lowermagnification, or of a larger field of view, and/or a different focalplane, than is used for viewing primary surgical manipulations thattarget structures inside the eye.

Additionally, as would be understood by skilled persons, when usingendoillumination, external microscopy illumination light sources, suchas a microscope light source external to the eye, are typically turnedoff, so that the illuminated interior portion of the eye viewablethrough the pupil of the endoilluminated eye is contrasted against apredominantly dark, or relatively non-illuminated exterior portion ofthe endoilluminated eye. For example, when using the exemplary NGENUITY®3D Visualization System for performing vitreoretinal surgery, theinterior of the eye is visualized by endoillumination, and externallight sources are typically turned off.

Accordingly, vitreoretinal surgery procedures that use endoilluminationtypically take place in a darkened operating room or generally takeplace wherein the secondary surgical field is relatively dark. As wouldbe understood by skilled persons, having a darkened operating room or arelatively dark secondary surgical field during vitreoretinal surgery isuseful for increased contrast of the endoilluminated image and reducingunwanted glare and glistening from the endoilluminated image. However,having a dark operating room or an otherwise relatively dark secondarysurgical field makes it difficult to adequately visualize the secondarysurgical field, and therefore makes it difficult to perform secondarysurgical manipulations and visual inspections of components in thesecondary surgical field in absence of illumination of the secondarysurgical field. The terms “darkened” or “relatively dark” as used hereinrefer to light levels that are below, or about below, 2000 lux.

Accordingly, previous approaches for viewing the secondary surgicalfield during vitreoretinal surgery typically involve turning on a lightsource external to the eye, in order to illuminate the secondarysurgical field for viewing.

In addition, one previous approach for visualizing the secondarysurgical field involves zooming out the field of view and/or adjustingthe focal plane of the surgical microscope from the primary surgicalfield to allow visualization of the secondary surgical field using thesurgical microscope. Using this approach, after performing exteriorsurgical manipulations and/or visual inspections in the externalsurgical field, the surgical microscope must be zoomed in again and/orrefocused so that the surgical microscope's field of view is againdirected to the primary surgical field, and the external illuminationturned off. It will be apparent to skilled persons that this previousapproach has disadvantages, as it is cumbersome and interrupts thesurgical procedure, as it requires time and readjustment of themicroscope, which lengthens the time required for surgery.

As an alternative to zooming out the surgical microscope field of view,another previous approach for viewing the external surgical field duringvitreoretinal surgery involves the use of an auxiliary optical lens suchas a loupe or magnifying glass, or an auxiliary set of lowermagnification eyepieces, configured to provide the ophthalmic surgeonwith an overview of the secondary surgical field. For example, oneprevious approach uses an auxiliary magnifying glass or loupeadditionally attached to the housing of the surgical microscope near thesurgical microscope oculars. This previous approach also hasdisadvantages. For example, using such an approach the external fieldviewable through such auxiliary optics is only viewable by theophthalmic surgeon, and is not simultaneously viewable by otherpersonnel in the operating room. Additionally, use of auxiliary opticalmagnifying glasses or auxiliary eyepieces also typically requires thatexternal lights be turned on to adequately illuminate the externalsurgical field for viewing.

Described herein is an auxiliary surgical field visualization systemthat may be used during ophthalmic surgery, such as vitreoretinalsurgery, to allow the ophthalmic surgeon, and others in the operatingroom, to conveniently view the secondary surgical field therebyconveniently allowing visualization of secondary surgical manipulationsand performance of visual checks of components outside of the primarysurgical field of view.

In particular, upon reading of the present disclosure, it will beapparent to skilled persons that the auxiliary surgical fieldvisualization system described herein has various advantages overprevious approaches in that it allows, for example, various secondarysurgical manipulations and visual checks in the secondary surgical fieldto be performed without the need to refocus the field of view of thesurgical microscope away from the primary surgical field. Accordingly,the surgical microscope can remain focused on the primary surgicalfield. In addition, the auxiliary surgical field visualization systemdescribed herein allows the ophthalmic surgeon and others in a surgicalteam in the operating room, such as nurses and technicians, tosimultaneously view the external surgical field, which allows thesurgical team to have improved understanding of the surgical procedurein process, improved communication and improved workflow between membersof the surgical team.

FIG. 3A is a schematic showing an implementation of an exemplaryauxiliary surgical field visualization system. Shown in FIG. 3A is aside-view of an eye undergoing a vitreoretinal surgical procedure asshown in FIG. 1, including various tools inserted into the eye,including the vitrector cutting device 101, the light pipe 102, and theinfusion cannula 103, inserted into the eye through respective trocarcannulas 104, 105 and 106. In FIG. 3A, the primary surgical fieldincluding the illuminated portion of the fundus 107 and other internalstructures of the eye are viewed through the pupil 108 using a surgicalmicroscope 301, for example having eyepieces 302. Dashed lines 303indicate exemplary boundaries of the field of view of the primarysurgical field as viewed by the surgical microscope 301. The auxiliarysurgical field visualization system includes an auxiliary camera 304.The auxiliary surgical field camera is configured for acquiring an imageof a field of view of a secondary surgical field, wherein the secondarysurgical field includes the exterior of a patient's eye undergoingvitreoretinal surgery. Dashed lines 305 indicate exemplary boundaries ofthe field of view of the secondary surgical field. A display, referredto as an auxiliary display 306, in electronic communication 307 with theauxiliary surgical field camera 304, is configured for receiving, fromthe auxiliary surgical field camera 304, a signal that includes theimage of the field of view of the secondary surgical field, and uponreceiving the signal, displaying the image of the field of view of thesecondary surgical field. Solid lines 307 herein indicate electronic orelectrical communication and may in various implementations be wired orwireless communication. Dashed lines 303 and 305 herein indicateexemplary boundaries of an optical field of view respectively of aprimary surgical field and a secondary surgical field.

The term “camera” as used herein refers to a device that includes aphotosensor. A photosensor is an electromagnetic sensor that responds tolight and produces or converts it to an electrical signal which can betransmitted to a receiver for signal processing or other operations andultimately read or viewed by an instrument or an observer.

Accordingly, a camera is a device used to capture images, either asstill photographs or as sequences of moving images (movies or videos). Acamera generally consists of an enclosed hollow with an opening(aperture) at one end for light to enter, and a recording or viewingsurface for capturing the light at the other end. The recording surfacecan be chemical, as with film, or electronic. Cameras can have a lenspositioned in front of the camera's opening to gather the incoming lightand focus all or part of the image on the recording surface. Thediameter of the aperture is often controlled by a diaphragm mechanism,but alternatively, where appropriate, cameras have a fixed-sizeaperture.

Exemplary electronic photosensors in accordance with the presentdisclosure include, but are not limited to, complementarymetal-oxide-semiconductor (CMOS) sensors or charge-coupled device (CCD)sensors. Both types of sensors perform the function of capturing lightand converting it into electrical signals. A CCD is an analog device.When light strikes the CCD it is held as a small electrical charge. Thecharges are converted to voltage one pixel at a time as they are readfrom the CCD. A CMOS chip is a type of active pixel sensor made usingthe CMOS semiconductor process. Electronic circuitry generally locatednext to each photosensor converts the received light energy into anelectrical voltage and additional circuitry then converts the voltage todigital data which can be transmitted or recorded.

The real-time video signal transmitted can be a digital video signalwhich is a digital representation of discrete-time signals. Often times,digital signals are derived from analog signals. As would be understoodby persons skilled in the art, a discrete-time signal is a sampledversion of an analog signal where the value of the datum is noted atfixed intervals (for example, every microsecond) rather than notedcontinuously. Where the individual time values of the discrete-timesignal, instead of being measured precisely (which would require aninfinite number of digits), are approximated to a certainprecision—which, therefore, only requires a specific number ofdigits—then the resultant data stream is termed a “digital” signal. Theprocess of approximating the precise value within a fixed number ofdigits, or bits, is called quantization. Thus, a digital signal is aquantized discrete-time signal, which in turn is a sampled analogsignal. Digital signals can be represented as binary numbers, so theirprecision of quantization is measured in bits.

It will be appreciated by those of ordinary skill in the art that theauxiliary surgical field camera described herein includes, in someimplementations, a camera configured to acquire an image correspondingto an optical view of a secondary surgical field and transmit thatinformation as a real-time video signal that can be recorded orpresented for display and viewing.

In some implementations, the transmitted digital video signal is capableof producing an image having a suitable resolution, such as a resolutionof at least about 1280 lines by 720 lines. This resolution correspondsto the typically minimum resolution for what one of ordinary skill inthe art would consider to be high definition or an HD signal. Othersuitable resolutions are also contemplated, such as standard resolution,e.g. 640 lines by 480 lines, and so on.

“Real-time” as used herein generally refers to the updating ofinformation at the same rate as data is received. More specifically, inthe context of the present invention “real-time” means that the imagedata is acquired, processed, and transmitted from the photosensor at ahigh enough data rate and a low enough delay that when the data isdisplayed objects move smoothly without user-noticeable judder orlatency. Typically, this occurs when new images are acquired, processed,and transmitted at a rate of at least about 30 frames per second (fps)and displayed at about 60 fps and when the combined processing of thevideo signal has no more than about 1/30^(th) second of delay.

In the auxiliary surgical field visualization system described herein,the video signal is received and presented on a video display havingcorresponding resolution capabilities. Exemplary visual displays includecathode ray tubes, projection screens, liquid crystal displays, organiclight emitting diode displays, plasma display panels and light emittingdiode displays, among others identifiable by skilled persons.

The auxiliary camera can be either a conventional camera or a 3D camerawith two lenses. The auxiliary camera described herein may in someimplementations include stereoscopic lenses configured to provide astereoscopic 3-dimensional image. When the real-time video signaldescribed herein includes multiple views of the target object or tissuethe video display can be made three dimensional (“3D”) so that depth offield is presented to the ophthalmic surgeon. Exemplary types of highresolution 3D video displays include stereoscopic 3D displays usingpolarized glasses such as those developed by TrueVision Systems, Inc.Alternatively, autostereoscopic 3D displays that do not require the useof any special glasses or other head gear to direct different images toeach eye can be used. Similarly, holographic 3D displays are alsocontemplated as being within the scope of the present disclosure.

The auxiliary surgical field camera may have one or more lensesconfigured to provide a suitable magnification of the external surgicalfield. For example, one or more lenses configured to provide amagnification between, or between about, 1× to 10× may be used in theauxiliary surgical field camera. For example, the magnification may bebetween, or between about, 1×-1.5×, 1.5-2×, 2×-2.5×, 2.5×-3×, 3×-3.5×,3.5×-4×, 4×-4.5×, 4.5×-5×, 5×-5.5×, 5.5×-6×, 6×-6.5×, 6.5×-7×, 7×-7.5×,7.5×-8×, 8×-8.5×, 8.5×-9×, 9×-9.5×, or 9.5×-10×.

As will be understood by skilled persons, the magnification leveltypically employed by the auxiliary surgical field camera will berelatively lower than the high magnification used by the surgicalmicroscope for viewing the primary surgical field. The term “highmagnification” as used herein may refer to any value or range ofmagnification that may be typically used for visualization of primarysurgical manipulations during ophthalmic surgery, such as vitreoretinalsurgery, identifiable by skilled persons. For example, in someimplementations, an exemplary high magnification may refer to amagnification value within a range of about 2× to 100×, or about 10× to40×, or about 10× to 20×, among other ranges identifiable by skilledpersons. In some implementations, high magnification may refer to amagnification value of about 5× to 20×, 10× to 15×, or 10×, 15× or 20×.

The magnification of a particular auxiliary surgical field visualizationsystem, or a surgical microscope, may be calculated by taking intoaccount factors of lenses, such as the focal length, and themagnification factor set on the zoom components of the system, amongother factors identifiable by skilled persons. Methods and systems thatinclude components having optical and/or digital zoom capability arecontemplated in the present disclosure.

The photosensor of a camera may be capable of responding to or detectingany or all of the wavelengths of light that form the electromagneticspectrum. Alternatively, the photosensor may be particularly sensitiveto a more restricted range of wavelengths. In particular, in someimplementations described herein, because vitreoretinal surgery istypically performed in a darkened operating room, the auxiliary surgicalfield camera described herein may include a photosensor suitable forcapturing an infrared image, a low light image, or a night vision image.

As would be understood by skilled persons, the term “infrared camera”,otherwise known as a thermographic camera or a thermal imaging camera,is a device that forms an image using infrared radiation, similar to acommon camera that forms an image using visible light. Infraredwavelengths extend from the nominal red edge of the visible spectrum at700 nanometers (frequency 430 THz), to 1 millimeter (300 GHz). Insteadof the typical 400-700 nm range of the visible light camera, infraredcameras may typically operate in wavelengths as long as 14,000 nm (14μm). Lenses used in infrared cameras are typically made from materialssuch germanium or sapphire crystals rather than glass, as glass blockslong-wave infrared light. Images from infrared cameras may be monochromeor pseudo-colored. Thermographic cameras can be broadly divided into twotypes: those with cooled infrared image detectors and those withuncooled detectors. Cooled detectors are typically contained in avacuum-sealed case or dewar and cryogenically cooled. The cooling istypically necessary for the operation of the semiconductor materialsused. Materials used for cooled infrared detection includephotodetectors based on a wide range of narrow gap semiconductorsincluding indium antimonide (3-5 μm), indium arsenide, mercury cadmiumtelluride (MCT) (1-2 μm, 3-5 μm, 8-12 μm), lead sulfide, and leadselenide. Infrared photodetectors can be created with structures of highband gap semiconductors such as in Quantum well infrared photodetectors.Uncooled thermal cameras use a sensor operating at ambient temperature,or a sensor stabilized at a temperature close to ambient using smalltemperature control elements. Modern uncooled detectors typically usesensors that work by the change of resistance, voltage or current whenheated by infrared radiation. These changes are then measured andcompared to the values at the operating temperature of the sensor.Uncooled detectors are mostly based on pyroelectric and ferroelectricmaterials or microbolometer technology. The materials are used to formpixels with highly temperature-dependent properties, which are thermallyinsulated from the environment and read electronically. Ferroelectricdetectors operate close to phase transition temperature of the sensormaterial; the pixel temperature is read as the highlytemperature-dependent polarization charge. Silicon microbolometersinclude a layer of amorphous silicon, or a thin film vanadium oxidesensing element suspended on silicon nitride bridge above thesilicon-based scanning electronics. Materials used for the uncooledfocal plane sensor arrays include amorphous silicon (a-Si), vanadium (V)oxide (VOx), lanthanum barium manganite (LBMO), lead zirconate titanate(PZT), lanthanum doped lead zirconate titanate (PLZT), lead scandiumtantalate (PST), lead lanthanum titanate (PLT), lead titanate (PT), leadzinc niobate (PZN), lead strontium titanate (PSrT), barium strontiumtitanate (BST), barium titanate (BT), antimony sulfoiodide (Sb SI), andpolyvinylidene difluoride (PVDF), among others identifiable by skilledpersons. Examples of commercially available infrared cameras includethermography cameras available from vendors such as FLIR and FLUKE,among others identifiable by skilled persons.

The term “low light camera” as used herein refers to a camera that mayhave a wide aperture lens allowing more photons to hit the photosensorand/or a photosensor with increased sensitivity. As would be understoodby skilled persons, the lens aperture is usually specified as anf-number, the ratio of focal length to effective aperture diameter. Alens typically has a set of marked “f-stops” that the f-number can beset to. A lower f-number denotes a greater aperture opening which allowsmore light to reach the film or image sensor. The photography term “onef-stop” refers to a factor of √2 (approx. 1.41) change in f-number,which in turn corresponds to a factor of 2 change in light intensity.For example, typical ranges of apertures used in cameras are aboutf/2.8-f/22 or f/2-f/16, covering 6 stops, which may for example bedivided into wide, middle, and narrow of 2 stops each, approximatelyf/2-f/4, f/4-f/8, and f/8-f/16 or (for a slower lens) f/2.8-f/5.6,f/5.6-f/11, and f/11-f/22. High sensitivity photosensors are typicallydesigned with large pixels so that they have a large area to collectlight. Photosensors used in low light cameras also typically have highquantum efficiency for converting light photons to electrons. Highsensitivity sensors include, for example, doped silicon sensors foroptimal photon conversion of light wavelengths in the visible lightspectrum. Some low light cameras use frame transfer or full framesensors and so use the full pixel area for light collection. Other lowlight cameras include a microlens located over every pixel to collectlight from a larger area and focus it onto the smaller light collectingpixel area.

The term “night vision” can be broadly divided into three maincategories: image intensification, active illumination and thermalimaging. For example, an image intensifier may refer to a vacuum tubedevice for increasing the intensity of available light to allow useunder low-light conditions, or for conversion of non-visible lightsources, such as near-infrared or short wave infrared to visible. Imageintensifiers typically operate by converting photons of light intoelectrons, amplifying the electrons (e.g., with a microchannel plate),and then converting the amplified electrons back into photons forviewing. For example, image intensifiers are used in devices such asnight vision goggles. In image intensifiers, when light strikes acharged photocathode plate, electrons are emitted through a vacuum tubethat strike the microchannel plate that cause the image screen toilluminate with a picture in the same pattern as the light that strikesthe photocathode, and is on a frequency that the human eye can see.Active illumination couples imaging intensification technology with anactive source of illumination in the near infrared (NIR) or shortwaveinfrared (SWIR) band. Examples of such technologies include various lowlight cameras. Active infrared night-vision typically combines infraredillumination of spectral range 700-1,000 nm (just below the visiblespectrum of the human eye) with CCD cameras sensitive to this light. Theresulting image is typically displayed in monochrome. Laser range gatedimaging is another form of active night vision which utilizes a highpowered pulsed light source for illumination and imaging. Range gatingis a technique which controls the laser pulses in conjunction with theshutter speed of the camera's detectors. Gated imaging technology can bedivided into single shot, where the detector captures the image from asingle light pulse, and multi-shot, where the detector integrates thelight pulses from multiple shots to form an image.

During ophthalmic surgery, because of the small size and delicate natureof the eye structures, surgeons typically use a microscope to magnifyvisualization of a patient's eye or a part of the eye that is beingoperated on. Typically, in the past, during ophthalmic surgery, surgeonsused eyepieces, otherwise known as oculars, to view the eye or partthereof that is being magnified by the microscope. During ophthalmicsurgery, stereo microscopes having two eyepieces viewable by both eyessimultaneously for binocular view are typically used. Some ophthalmicsurgery procedures can take several hours to perform, and thereforepreviously, during ophthalmic surgery, ophthalmic surgeons would oftenbe required to look through the binocular eyepieces of their microscopesfor hours on end.

More recently, as an alternative to using eyepieces, or in addition,during ophthalmic surgery, developments in digital microscopy haveallowed an image of the eye or part thereof that is magnified by themicroscope to be displayed on a screen viewable by the surgeon and otherpersonnel in an operating room. Among the benefits of using a displayscreen, rather than using microscope oculars, to visualize eyestructures during ophthalmic surgery include decreased fatigue andincreased comfort for the surgeon. In addition, unlike microscopesoculars, because the display can be viewed by more than one person at atime, the use of a display is useful for teaching and improvescommunication regarding the surgical procedure between personnel in theoperating room.

FIG. 3B is a schematic showing another implementation of an exemplaryauxiliary surgical field visualization system. As in FIG. 3A, theauxiliary surgical field visualization system includes an auxiliarycamera 304 configured for acquiring an image of a field of view of thesecondary surgical field, shown by dashed lines 305 indicating exemplaryboundaries of the field of view of the secondary surgical field. Anauxiliary display 306, in electronic communication 307 with theauxiliary surgical field camera 304, is configured for receiving, fromthe auxiliary surgical field camera 304, a signal comprising the imageof the field of view of the secondary surgical field, and upon receivingthe signal, displaying the image of the field of view of the secondarysurgical field. In contrast to the exemplary implementation shown inFIG. 3A, the exemplary implementation shown in FIG. 3B includes adigital surgical microscope 301 in electronic communication 307 with adigital primary camera 308 configured for capturing an image of theprimary surgical field indicated by dashed lines 303. In FIG. 3B, adisplay 309 receives a signal from the primary camera 308. Accordingly,the exemplary auxiliary surgical field visualization system shown inFIG. 3B has a separate auxiliary display 306 to the display 309 used fordisplaying the magnified image of the primary surgical field 303.

Ophthalmic surgery visualization platforms utilizing digital microscopyand display screens applicable to various implementations of the systemdescribed herein generally include at least one high resolutionphotosensor such as a camera or charge coupled device (CCD) which iscapable of receiving and acquiring a plurality of optical views of aneye under magnification by a microscope. Those skilled in the art willappreciate that receiving light in visible wavelengths in addition towavelengths outside of the wavelengths of normal visible light is alsowithin the scope of the present disclosure. In general, the highresolution photosensor then transmits a resultant real-timehigh-resolution video signal which is transmitted, either directly orvia a processor executing instructions contained in a non-transitorycomputer readable medium, to at least one high resolution video display.In some configurations, because of the multiple high resolution opticalviews transmitted and presented on the display, the operator of thevisualization platform, or others, is able to view a real-time highdefinition three-dimensional visual image of the target object ortissue.

Exemplary real-time visualization platforms suitable for implementingthe system described herein include those described U.S. Pat. Nos.9,168,173, 8,339,447, and 8,358,330, all of which are herebyincorporated by reference.

The term “display” as used herein refer to any device capable ofdisplaying a still or video image. Preferably, the displays of thepresent disclosure display high definition (HD) still images and videoimages or videos which provide a surgeon with a greater level of detailthan a standard definition (SD) signal. In some implementations, thedisplays present such HD stills and images in three dimensions (3D).Exemplary displays include HD monitors, cathode ray tubes, projectionscreens, liquid crystal displays, organic light emitting diode displays,plasma display panels, light emitting diodes (LED) or organic LED(OLED), 3D equivalents thereof and the like. 3D HD holographic displaysystems are considered to be within the scope of the present disclosure.

Examples of systems for digital microscopy that utilizes display screensfor visualization during ophthalmic surgery include Alcon LaboratoriesNGENUITY® 3D Visualization System (Alcon, Inc. Corporation Switzerland,Hunenberg Switzerland), a platform for Digitally Assisted VitreoretinalSurgery (DAVS). The NGENUITY® 3D Visualization System allows retinalsurgeons to visualize the primary surgical field on a high definition 3Dscreen, instead of looking through the eye-piece of a surgicalmicroscope.

In some implementations, the auxiliary surgical field visualizationsystem described herein may further include a processor and anon-transitory computer-readable medium, also referred to herein as“memory”, accessible by the processor, wherein the non-transitorycomputer readable medium contains instructions executable by theprocessor for receiving, from the auxiliary surgical field camera, asignal that includes the image of the field of view of the secondarysurgical field, and upon receiving the signal, sending the signal to adisplay.

For example, FIG. 3C is a schematic showing another exemplaryimplementation of the auxiliary surgical field visualization system,including an auxiliary camera 304 configured for acquiring an image of afield of view of the secondary surgical field, shown by dashed lines 305indicating exemplary boundaries of the field of view of the secondarysurgical field. The exemplary implementation of the auxiliary surgicalfield visualization system includes a processor 310 and a memory 311accessible by the processor 310, wherein the memory 311 containsinstructions executable by the processor 310 for receiving, from theauxiliary surgical field camera 304, a signal that includes the image ofthe field of view of the secondary surgical field 305, and uponreceiving the signal, sending the signal to the auxiliary display 306.

For example, the processor 310 may include any suitable computer havingan operating system such as those of UNIX or UNIX-like operating system,a Windows family operating system, or another suitable operating system.The non-transitory computer-readable medium or memory 311 may encompasspersistent and volatile media, fixed and removable media, and magneticand semiconductor media, among others identifiable by persons ofordinary skill in the art. In addition, any suitable communicationinterface identifiable by skilled persons can be used as means fortransmittal and receipt of electronic communication signals between thecomponents of the auxiliary surgical field visualization systemdescribed herein.

FIG. 3D is a schematic showing yet another exemplary implementation ofthe auxiliary surgical field visualization system. FIG. 3D shows theauxiliary camera 304 configured for acquiring an image of a field ofview of the secondary surgical field, shown by dashed lines 305indicating exemplary boundaries of the field of view of the secondarysurgical field. The exemplary implementation of the auxiliary surgicalfield visualization system includes the processor 310 and the memory 311accessible by the processor 310, wherein the memory 311 containsinstructions executable by the processor 310 for receiving, from theauxiliary surgical field camera 304, a signal that includes the image ofthe field of view of the secondary surgical field 305, and uponreceiving the signal, sending the signal to the display 309. In theexemplary implementation shown in FIG. 3D, the memory 311 also containsinstructions executable by the processor 310 for receiving, from theprimary surgical field camera 308 configured for acquiring an image of afield of view of a primary surgical field indicated by dashed lines 303including an internal view of a patient's eye undergoing vitreoretinalsurgery, a signal that includes the image of the field of view of theprimary surgical field, and upon receiving the signal, sending thesignal to the display 309. Accordingly, in various implementations, theimage of the secondary surgical field may be displayed on an auxiliarydisplay 306, such as shown in FIG. 3A, FIG. 3B, or FIG. 3C, oralternatively may be displayed on the same display 309 as the primarysurgical field image, for example, either a 2D display, or a 3D display,such as those used in the NGENUITY® system. Accordingly, the exemplaryauxiliary surgical field visualization system shown in FIG. 3D isconfigured in some implementations for displaying the image of thesecondary surgical field and/or the primary surgical field. In someimplementations, the auxiliary surgical field visualization system isconfigured for simultaneously displaying the images of the field of viewof the secondary surgical field and the field of view of the primarysurgical field.

In some implementations, the processor 310 and the memory 311 may beoptional, in that the display 309 may be configured to either directlyor indirectly receive, from the primary camera 308, a signal thatcontains an image of the primary surgical field, and to directly orindirectly receive, from the auxiliary camera 304, a signal thatcontains an image of the secondary surgical field.

In some implementations, the auxiliary surgical field visualizationsystem described herein may further include a control panel or othersuitable user interface accessible to a user, such as the surgeon orothers in the surgical team, wherein the control panel is in electroniccommunication with the auxiliary surgical field visualization system andis configured to allow a user to select between the image of the primarysurgical field of view and/or the secondary surgical field of view to bedisplayed on the display.

As shown in an exemplary schematic in FIG. 4, in some implementations,the image of the primary surgical field of view 401 and the image of thesecondary surgical field of view 402 may be simultaneously displayed onthe display 403 as a “picture-in-picture” arrangement. For example, thepicture-in picture arrangement may be displayed on a display such asused in an NGENUITY® system. As would be understood by skilled persons,the term “picture-in-picture” as used herein refers to an arrangementwherein one image is displayed as an inset of another image. In variousimplementations, the image of the secondary surgical field may bedisplayed as an inset to the image of the primary surgical field, orvice-versa. In other implementations, the simultaneously displayedimages of the primary surgical field and the secondary surgical fieldmay be displayed side by side, or any other suitable arrangement on asingle display. In various implementations, the primary surgical fieldimage may be displayed approximately the same size, or larger or smallerthan the secondary surgical field image.

FIG. 5 is a schematic showing an exemplary location of an auxiliarycamera included in the auxiliary surgical field visualization system asdescribed herein. FIG. 5 shows an ophthalmic surgeon 501 operating on apatient 502. The auxiliary camera 503 is shown mounted, or attached, onthe housing of a surgical microscope 504. Panel A shows an exemplaryoptical path of the field of view of the primary surgical field 505 asviewed through the surgical microscope 504, and Panel B shows anexemplary optical path of the field of view of the secondary surgicalfield 506 as viewed through the auxiliary camera 503. The auxiliarycamera 503 may be located in different positions to that shown in FIG.5. Other suitable positions allowing the auxiliary camera to capture animage of the secondary surgical field are identifiable by persons ofordinary skill in the art upon reading of the present disclosure.

The above disclosed subject matter is to be considered illustrative, andnot restrictive, and the appended claims are intended to cover all suchmodifications, enhancements, and other implementations which fall withinthe true spirit and scope of the present disclosure. Thus, to themaximum extent allowed by law, the scope of the present disclosure is tobe determined by the broadest permissible interpretation of thefollowing claims and their equivalents and shall not be restricted orlimited by the foregoing detailed description.

As used in this specification and the appended claims, the singularforms “a,” “an,” and “the” include plural referents unless the contentclearly dictates otherwise. The term “plurality” includes two or morereferents unless the content clearly dictates otherwise. Unless definedotherwise, all technical and scientific terms used herein have the samemeaning as commonly understood by one of ordinary skill in the art towhich the disclosure pertains.

1. An auxiliary surgical field visualization system comprising: anauxiliary surgical field camera, configured for acquiring an image of afield of view of a secondary surgical field, wherein the secondarysurgical field comprises the exterior of a patient's eye undergoingvitreoretinal surgery; and a display in electronic communication withthe auxiliary surgical field camera, wherein the display is configuredfor receiving, from the auxiliary surgical field camera, a signalcomprising the image of the field of view of the secondary surgicalfield, and upon receiving the signal, displaying the image of the fieldof view of the secondary surgical field.
 2. The auxiliary surgical fieldvisualization system of claim 1, wherein the eye is illuminated usingendoillumination.
 3. The auxiliary surgical field visualization systemof claim 1, wherein the secondary surgical field has a light intensityof less than 2000 lux.
 4. The auxiliary surgical field visualizationsystem of claim 1, wherein the auxiliary surgical field camera is aninfra-red camera, a low-light camera, or a night vision camera.
 5. Theauxiliary surgical field visualization system of claim 1, wherein thearea of the field of view of the secondary surgical field is betweenabout 1 cm² and 36 cm².
 6. The auxiliary surgical field visualizationsystem of claim 1, wherein the image is a real-time image.
 7. Theauxiliary surgical field visualization system of claim 1, wherein: thedisplay is further configured to receive, from a primary surgical fieldcamera configured for acquiring an image of a field of view of a primarysurgical field comprising an internal view of a patient's eye undergoingvitreoretinal surgery, a signal comprising the image of the field ofview of the primary surgical field, and displaying the image of thefield of view of the primary surgical field.
 8. The auxiliary surgicalfield visualization system of claim 7, wherein the display is configuredfor simultaneously displaying the image of the field of view of thesecondary surgical field and the field of view of the primary surgicalfield.
 9. The auxiliary surgical field visualization system of claim 1,wherein the display is a standard definition (SD) display, a highdefinition (HD) display, a cathode ray tube (CRT) display, a projectionscreen display, a liquid crystal display (LCD), an organic lightemitting diode (OLED) display, a plasma display, a light emitting diodes(LED) display, or a 3-dimensional (3D) display.
 10. The auxiliarysurgical field visualization system of claim 1, comprising an NGENUITY®3D Visualization System.
 11. The auxiliary surgical field visualizationsystem of claim 1, further comprising: a processor; and a non-transitorycomputer-readable medium accessible by the processor, wherein thenon-transitory computer readable medium contains instructions executableby the processor for: receiving, from the auxiliary surgical fieldcamera, a signal comprising the image of the field of view of thesecondary surgical field, and upon receiving the signal, sending thesignal to the display.
 12. The auxiliary surgical field visualizationsystem of claim 11, wherein the non-transitory computer-readable mediumfurther comprises instructions executable by the processor for:receiving, from a primary surgical field camera configured for acquiringan image of a field of view of a primary surgical field comprising aninternal view of a patient's eye undergoing vitreoretinal surgery, asignal comprising the image of the field of view of the primary surgicalfield, and upon receiving the signal, sending the signal to the display.13. The auxiliary surgical field visualization system of claim 1,wherein the auxiliary surgical field visualization system allowsvisualization on a display of one or more secondary surgicalmanipulations, wherein the secondary surgical manipulations are directedto a site on or adjacent to the exterior surface of the eye.
 14. Theauxiliary surgical field visualization system of claim 13, wherein thesecondary surgical manipulations comprise one or more manipulationsselected from inserting an instrument into the eye through a trocarcannula, suturing an exterior surface of the eye, placing a trocarcannula, removing a trocar cannula, inspecting a function of a surgicalcomponent, retrieving a foreign body, placing indentors or muscle hooks,using cryo-probes, placing scleral buckles and encircling bands, andplacing a direct or an indirect contact lens
 15. The auxiliary surgicalfield visualization system of claim 1, wherein the auxiliaryvitreoretinal surgery visualization system allows visualization on adisplay of one or more surgical components in the secondary surgicalfield.
 16. The auxiliary surgical field visualization system of claim15, wherein the surgical components in the secondary surgical field areselected from a trocar cannula, an infusion line, a needle holder, anindentor, a muscle hook, an instrument tip prior to insertion trough atrocar cannula, a flexible iris retractor, a direct or indirect contactlens, and a needle and suture.
 17. The auxiliary surgical fieldvisualization system of claim 1, wherein the display is viewable by aplurality of individuals.